Journal of Psychopharmacology

Trauma has an enormous impact on both individuals and society as a whole. Recognition of the extent of this impact by the medical profession has been relatively slow but, with our growing appreciation of the prevalence of trauma exposure in civilian as well as combat populations, the true scale of trauma-related psychiatric consequences is beginning to emerge. It has been reported that more than 60% of men and 51% of women experience at least one traumatic event in their lifetimes. Of these, 8% and 20%, respectively, fall victim to post-traumatic stress disorder (PTSD) indicating that more women are at risk for developing PTSD. Individuals experience severe psychiatric stress that is compounded by significant comorbid illness. This impacts critically upon quality of life resulting in grave functional and emotional impairment. In addition, there is a detrimental cost to society with high financial and social consequences from the significantly elevated rates of hospitalization, suicide attempts and alcohol abuse.

Social phobia is the most common anxiety disorder in the community with a prevalence rate in the range of 5–8%. The problem most often emerges in childhood or adolescence. Individuals with generalized social phobia are at risk of developing other psychiatric disorders such as major depression, alcohol abuse and other anxiety disorders. Sufferers of social phobia often do not seek treatment until they encounter difficulty with comorbid disorders. Recent research indicates that social anxiety disorder is associated with higher levels of disability and greater reductions in quality of life than previously understood, with difficulties encountered in social relationships, education and employment. In previous years, there has been little or no known available effective treatment, and the disorder frequently goes unrecognized in primary care. However, new pharmacological (selective serotonin reuptake inhibitors, SSRIs) and psychological treatments are emerging that are able to produce significant symptom reduction and improvements in functioning and quality of life. In recent years, the SSRIs have been the focus of considerable research and are becoming one of the first-line treatments for social phobia. Early intervention in social phobia may improve quality of life, reduce disability and reduce the development of comorbid disorders.

Panic disorder is a chronic condition typically associated with significant distress and disability. In addition to the acute distress associated with the panic attack itself, the disorder often leads to distressing anticipatory anxiety and phobic avoidance. Affected individuals experience significant impairment in social and vocational functioning, high utilization of medical resources, constriction of function, premature mortality and diminution in overall quality of life. Panic disorder is frequently comorbid with other conditions, particularly depression, as well as alcohol and other substance abuse, and other anxiety disorders including social phobia, generalized anxiety disorder, obsessive-compulsive disorder and posttraumatic stress disorder. A number of pharmacological agents and cognitive-behavioural treatments have been shown to be effective in the treatment of panic disorder, with the selective serotonin reuptake inhibitors (SSRIs) becoming first-line pharmacotherapy for this condition. Among these, the SSRI sertraline appears effective not only in improving symptoms of panic, but also in reducing anticipatory anxiety and improving multiple aspects of quality of life. For patients who remain partly or fully symptomatic despite adequate first-line treatment, a variety of strategies are emerging for the management of refractory conditions. We provide an overview of the prevalence, presentation and associated complications of panic disorder, review the therapeutic options and discuss the management of refractory patients.

In the development of the majority of children, ritualistic behaviour may be seen as a normal phenomenon. In some children and adolescents, however, these rituals become time-consuming, interfering, irritating and annoying. The most common obsessions in both children and adults with obsessive–compulsive disorder (OCD) are related to a fear of dirt and contamination, fear of some terrible happening, and the fear of harming a loved one. The most common compulsions are washing fixations, checking behaviour and rituals (including mental rituals). Prevalence studies show that OCD in children and adolescents is far more common than previously thought. It is estimated that up to 2% of this population have symptoms fulfilling OCD criteria. The impact of early OCD onset can be profound, with long-term studies indicating that approximately 50% of these patients will also suffer from OCD in early adulthood. These patients tend to remain socially isolated, to have fewer relationships than their non-OCD peers, and have a tendency to remain within the family home during early adulthood. In addition, childhood OCD is associated with comorbid psychiatric disorders, in particular depression, anxiety and panic disorders, Tourette's syndrome and eating disorders. Treatment strategies for childhood OCD reflect those used in adult psychiatry. The most effective psychotherapeutic approach is based on cognitive-behavioural therapy with exposure and prevention. In contrast to pharmacotherapeutic agents without serotonin activity, the serotonin-specific antidepressants appear to be effective and well-tolerated in the treatment of OCD in children.

Disorders characterized by impulsivity include disorders of impulse control (intermittent explosive disorder, pyromania, kleptomania, pathological gambling and trichotillomania), paraphilias, sexual impulsions and sexual addictions and impulsive aggression personality disorders (borderline, antisocial, histrionic and narcissistic personality disorders). Impulsivity has a substantial impact on both individuals and society. Impulse control disorders may be conceptualized as a subset of the obsessive-compulsive spectrum. In this article, we examine the genetic and neurobiological aetiology of these disorders and possible treatment options. The link between serotonergic dysfunction and the pathophysiology of impulsivity is discussed, and studies that examine the efficacy of various selective serotonin reuptake inhibitors and other alternatives in the treatment of impulsive disorders such as pathological gambling, sexual addictions and borderline personality disorder are presented.